Robotic reconstruction of necrosed ileal ureter: Technical challenges, intra-operative difficulty, and learning points.

This video explores the challenges faced during a re-do robotic intra-corporeal ileal ureter reconstruction in a previously operated case. A 24-year-old woman presented with a 12-cm long stricture after robotic ileal ureter replacement surgery. A proper preoperative evaluation in the form of ureteroscopy and a nephrostogram is essential and the key steps include adhesiolysis, identification of the necrotic ileal ureter, and meticulous dissection. A 13-cm long segment of the ileum was isolated and was anastomosed to the renal pelvis and the bladder. The surgery lasted for 420 min with 300 ml of blood loss. Post-operatively, the patient recovered well and had a normal drainage with no complications at 1-year of follow-up. The factors such as a broad mesentery, a tension-free anastomosis, and avoiding the twisting of the pedicle are crucial for success of robotic ileal ureter replacement surgery.

Can we predict the incidence of high-grade Clavien-Dindo complications in patients with forgotten encrusted stents undergoing endourologic management?

Objective: Ureteral stents are customarily inserted to facilitate urinary drainage, but they come with their own glitches of being forgotten and/or encrusted leading to serious consequences. The present study aimed to report the complications in patients with forgotten and encrusted stents according to the Clavien-Dindo system specific to urological procedures and identify the factors leading to high-grade (Clavien-Dindo Grade 4A or above) complications. Methods: The hospital records of patients with forgotten encrusted double-J stents over a period of 8 years were reviewed. The parameters recorded included patient demographics, indwelling time, need for percutaneous nephrostomy, hemodialysis, urine culture, blood culture, total blood counts, serum creatinine, radiologic findings, management techniques, number of surgical interventions, modified Clavien-Dindo complications, follow-up, and mortality, if any. Results: Forty patients were included in the study. The median age was 52 (range 6-85) years. Of the total, 25 (62.5%) patients had a "significant" stent load; 31 (77.5%) had renal failure or acute kidney injury on presentation; 19 (47.5%) patients had sepsis at presentation. Among the patients presented with sepsis, 11 (57.9%) patients demonstrated a positive urine culture; and 7/11 (63.6%) patients exhibited pan-resistant organisms. Twelve out of 40 (30.0%) patients in our series developed high-grade Clavien-Dindo complications. On univariate analysis, sepsis at presentation (p=0.007), stent load (p=0.031), diabetes (p=0.023), positive urine culture (p=0.007), and stent indwelling time of more than 1 year (p=0.031) were found to be significant. On multivariate logistic regression analysis, sepsis at presentation (p=0.017) and positive urine culture (p=0.016) were significant predictors for high-grade complications. Conclusion: It is prudent to identify specific risk factors, namely sepsis at presentation and positive urine culture to triage and optimize these patients before surgical management.

Primary management of pelvic fracture urethral injury in a woman: challenges and outcome.

Literature on the management of pelvic fracture urethral injuries (PFUI) in women is scarce. We present a case of PFUI in a woman.A woman in her 50s presented with lower abdominal pain, bleeding per vaginum and inability to void following road traffic accident. Local examination showed mid-urethral transection injury and tear over the left anterolateral aspect of the vagina. Foley's catheter bulb and bony fragments of the fractured pelvis were palpable anteriorly. Imaging revealed bilateral superior and inferior rami fractures with pubic bone diastasis. She underwent external fixation of pelvic bones with primary repair of urethral and vaginal mucosal injury.Intraoperatively external pelvic fixator was applied, following which the bony fragments in the vagina were lifted up (due to the realignment of pelvic bones). Mid-urethral transection injury was repaired using end-to-end anastomotic urethroplasty. Per-urethral catheter and suprapubic catheter were placed. Periurethral tissue and vaginal layers were closed over the urethral repair. The postoperative course was uneventful.External pelvic fixator was removed after 6 weeks of surgery. Micturating cystogram showed no evidence of contrast extravasation. Follow-up at 3 months showed no urinary symptoms with a bell-shaped uroflowmetry curve.

Management Outcomes of Large Renal Angiomyolipoma Presenting with Wunderlich Syndrome-Experience from a Tertiary Center.

Renal angiomyolipoma is an uncommon, benign-mixed mesenchymal tumor consisting of thick-walled blood vessels, smooth muscles, and mature adipose tissues. Twenty percent of these tumors are associated with tuberous sclerosis. Wunderlich syndrome (WS), an acute nontraumatic spontaneous perirenal hemorrhage, can be a presentation of large angiomyolipoma. This study evaluated the presentation, management, and complications of renal angiomyolipoma with WS in eight patients who presented to the emergency department between January 2019 and December 2021. The presenting symptoms included flank pain, palpable mass, hematuria, and bleeding in the perinephric space on computerized tomography. Demographic data, symptoms at presentation, comorbidities, hemodynamic parameters, the association with tuberous sclerosis, transfusion requirements, need for angioembolization, surgical management, Clavien-Dindo complication, duration of hospital stay, and 30-day readmission rates were evaluated. The mean age of presentation was 38 years. Of the eight patients, five (62.5%) were females and 3(37.5%) were males. Two (25%) patients had tuberous sclerosis with angiomyolipoma, and three (37.5%) patients presented with hypotension. The mean packed cell transfusion was three units, and the mean tumor size was 7.85 cm (3.5-25 cm). Three of them (37.5%) required emergency angioembolization to prevent exsanguination. Embolization was unsuccessful in one patient (33%) who underwent emergency open partial nephrectomy, and one (33%) patient developed post-embolization syndrome. A total of six patients underwent elective surgery-four underwent partial nephrectomy (laparoscopic - 1, robotic - 1, open - 2) and two underwent open nephrectomy. Three patients encountered Clavien-Dindo complications (Grade 1, n = 2 and IIIA, n = 2). WS is a rare, life-threatening complication in patients with large angiomyolipoma. Judicious optimization, angioembolization, and prompt surgical intervention will help deliver better outcomes.

Outcomes of bladder neck botulinum toxin injection for female primary bladder neck obstruction-does subjective improvement correlate with an objective assessment?

INTRODUCTION AND HYPOTHESIS: Common options for management of primary bladder neck obstruction (PBNO) in women include medications and surgical treatment. Less invasive treatment such as bladder neck botulinum toxin injection can be an alternate therapy in patients with failed conservative management. In this study, we describe the subjective and objective outcomes, patient satisfaction, and willingness for repeat treatment with bladder neck botulinum toxin injection in females with PBNO. METHODS: A retrospective analysis of ten female PBNO patients managed with bladder neck botulinum toxin injection was performed. Subjective parameters were quantified with symptom assessment, International Prostate Symptom Score (IPSS), and Quality of life (QoL) score. Objective parameters were assessed with maximum flow rate (Qmax) in uroflowmetry and postvoid residual (PVR). RESULTS: The mean pre-treatment IPSS, QoL score, Qmax, PVR was 24.2 ± 5.0, 4.8 ± 0.63, 5.73 ± 3.18 ml/s, and 210 ± 66 ml, respectively. Seven of the ten patients subjectively improved (IPSS 12.9 ± 9.6, QoL2.9 ± 1.6, p < 0.05). Three patients improved objectively (mean Qmax 17.3 ± 2.7 ml/s, PVR 42.7 ± 7.5 ml, p < 0.05). Three patients accepted repeat botulinum toxin injection. Three patients who showed no improvement underwent bladder neck incision with resolution of symptoms. CONCLUSION: Botulinum toxin can be an intermediary therapy in female patients with PBNO who want a minimally invasive procedure.

"Labia Majora Fasciocutaneous Flap Reconstruction in Complex Urogynecological Fistulas With Vaginal Deficit - A Versatile Approach".

OBJECTIVE: To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of 7 cases. METHODS: Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last 3 years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all. RESULTS: All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of 6-month follow-up. CONCLUSION: Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

Clinical and videourodynamic study characteristics in female primary bladder neck obstruction and outcomes of bladder neck resection: A tertiary care center experience in India.

Introduction: Video urodynamic study (VUDS) with clinical correlation helps in diagnosing primary bladder neck obstruction (PBNO) in women. Bladder neck incision/bladder neck resection (BNR) though effective is not commonly practiced for the fear of complications and limited literature available. Methods: The records of ten women diagnosed with PBNO between 2017 and 2019 were reviewed and data pertaining to their clinical features, laboratory results, findings on abdominal ultrasonography, uroflowmetry, and VUDS was noted. Type of operative procedure performed and outcomes on follow-up were also assessed. Results: Out of ten patients, two presented with lower urinary tract symptoms (LUTS), three with voiding LUTS and chronic retention and five had acute urinary retention. Mean serum creatinine was 3.4 mg/dl. In those able to void, mean maximum flow rate (Q max) was 7 ml/sec, and mean postvoid residual volume (PVR) was 360 ml. On VUDS, mean detrusor pressure at maximum flow (pdet@Qmax) was 54.2 cm of H20. Three patients opted conservative treatment and 7 had a successful surgical outcome with mean Q max of 26.2 ml/s (range: 13.9-41 ml/s), insignificant PVR and resolution of renal failure. Patients with pdet@Qmax <20 cm H2O (n = 3, mean 18.3 cm H2O) did equally well as compared to those with pdet@Qmax >20 cm H2O (n = 4, mean 93 cm H2O). None of the patients developed any complications on follow-up. Conclusions: Clinical assessment supported with VUDS correlation holds a key in identifying patients with PBNO. BNR is a safe and effective treatment of PBNO in women who fail or are not candidates for conservative treatment.

Perioperative and oncological outcomes of renal cell carcinoma with venous tumour thrombus.

AIM: The aim of the present study is to report the perioperative and long-term surgical outcomes of renal cell carcinoma (RCC) with venous tumour thrombus (VTT). MATERIALS AND METHODS: Data of 34 patients (males = 23, females = 11) from 2009 to 2020 who underwent radical nephrectomy with thrombectomy for RCC and VTT was retrospectively analysed. The parameters recorded include tumour laterality, size, level of thrombus, surgical approach, blood loss, transfusion rates, operative time, hospital stay, Clavien complications, tumour histology, follow-up duration, local recurrence, distant metastasis, overall and cancer-specific survival rates. RESULTS: The extent of thrombus was level I in thirteen, level II in twelve, level III (a-1, b-2, c-1, d-2) in six and level IV in three patients respectively. Mean operative time was 320 (±145) min, mean blood loss was 1371.15 (±1020.8) ml and mean hospital stay was 9.6 (±7.4) days. Mean transfusion rate was 6.4 (±3.2) units. Three patients died within the first 30 days of surgery. Cardiopulmonary bypass (CPB) was utilized in three patients. Median follow-up period was 58 (Range: 4-101) months. A statistically significant correlation was found between operative time (p = 0.014) and median survival (p = 0.003) respectively and tumour thrombosis level. Nine patients died due to metastasis, and ten due to unrelated causes. The estimated actuarial survival rates at a median of 58 months were 35.3%. CONCLUSION: An accurate preoperative assessment of the thrombus extent with the involvement of a multidisciplinary team approach is crucial in achieving optimal surgical outcomes in patients of RCC with VTT, particularly with level III and IV thrombus.

Effect of preoperative finasteride on perioperative blood loss during transurethral resection of the prostate and on microvessel density in patients with benign prostatic hyperplasia: An open label randomized controlled trial.

OBJECTIVE: Transurethral resection of the prostate (TURP) is a common procedure for the treatment of benign prostatic hyperplasia (BPH). Previous studies on the effect of 5-alpha reductase inhibitors on perioperative blood loss in TURP and microvessel density (MVD) in the prostate are equivocal. We evaluated whether pretreatment with finasteride for 2 weeks before surgery can reduce perioperative blood loss in TURP and MVD in the prostate. MATERIALS AND METHODS: Sixty-eight patients of BPH planned for TURP were randomized into two groups. The study group comprising 34 patients was treated with finasteride (5 mg/day) for 2 weeks and the placebo group comprising 34 patients received placebo for 2 weeks, before TURP. Blood loss was measured in terms of a reduction in the blood hemoglobin (Hb) and hematocrit (HCT) levels between preoperative values and 24 h after surgery. MVD was measured in the resected prostate tissue stained with anti-CD31 monoclonal antibody. RESULTS: The reduction of Hb and HCT in the finasteride group was significantly lower than the reduction in the placebo group (P < 0.05). The artery (P = 0.005), vein (P = 0.05), and gland (P = 0.008) densities were significantly less in the finasteride group than in the placebo group. There was no significant correlation between blood loss and MVD. CONCLUSIONS: Our study suggests a clear advantage of the preoperative use of finasteride for 2 weeks by reducing the perioperative blood loss in TURP in patients with BPH. While there is a significant reduction in MVD in the prostate on treatment with finasteride, it is not clear that this is the mechanism of reduction in blood loss in TURP.

A rare case of giant chromophobe renal cell carcinoma with sarcomatoid differentiation: Treatment and prognosis.

Chromophobe renal cell carcinoma (RCC) with sarcomatoid differentiation is an infrequent entity. In the current era of advanced imaging techniques, RCCs are usually detected in early stages, and a localized giant tumor is rarely encountered. Recently, we encountered a patient with a localized giant RCC, which was 36 cm in the largest dimension and weighing 5.1 kg, which was resected entirely but presented relapse and succumbed within 3 months of surgery.

Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Post Radiation Female Urethral Stricture - A Technical Appraisal With Outcomes.

INTRODUCTION AND OBJECTIVES: Female urethral stricture following radiation has been reported sparsely in the literature with just a handful of case reports. Radiation to the pelvis affects the genitourinary tracts and afflicts damage by causing periurethral fibrosis, necrosis, and subsequent tissue contraction, posing as a hurdle to the reconstructive surgeon. We studied the technique and outcomes of dorsal onlay buccal mucosal graft (BMG) urethroplasty in patients of radiation-induced female urethral stricture disease (FUSD). MATERIALS AND METHODS: Three cases of radiation-induced FUSD were reviewed. The preoperative and postoperative parameters like IPSS, Flow rate (Qmax), Postvoid residue (PVR), urethroscopy findings, and Videourodynamics study parameters were analyzed. All patients underwent dorsal onlay BMG urethroplasty. The salient steps of the operative procedure are demonstrated in this video presentation. RESULTS: The mean duration after the last radiation cycle was 2.33 years. Preoperatively mean IPSS, Qmax, and PVR were 27.33 ± 1.15, 6.46 ± 0.6 mL/s, and 56.67 ± 16.07 mL, respectively. After dorsal onlay BMG urethroplasty the mean IPSS, Qmax, and PVR were 3.33 ± 1.5, 23.33 ± 6.1 mL/s, 15.67 ± 8.14 mL, respectively. None of the patients reported bothersome lower urinary tract symptoms, and stricture recurrence in the 12-month follow-up. However, one patient had transient stress incontinence, which was managed conservatively. CONCLUSION: Dorsal onlay BMG urethroplasty achieves excellent outcomes in patients with postradiation FUSD. Adequate dorsal urethrotomy should be contemplated in previously irradiated strictures.

Managing intractable incontinence from a Yang-Monti channel in a case of enterocystoplasty with bladder neck closure - Challenges and a modified surgical technique.

Incontinence in the Mitrofanoff principle varies between 2% and 40% and is a challenging problem to treat. Incontinence is even more when a Yang-Monti channel is used with simultaneous enterocystoplasty, probably due to ineffective submucosal tunneling owing to the inferior quality of bowel mucosa. Here, we report the management options of such problems along with a novel surgical technique.

Do Primitive Neuroectodermal Tumors of the Kidney Have a Predilection for Inferior Vena Cava Involvement? A Case Series and Review of the Literature.

The primitive neuroectodermal tumor (PNET) of the kidney is an extremely rare neoplasm, the diagnosis of which mainly depends upon histopathology, immunohistochemistry (IHC), and cytogenetics. A handful of cases reported in the literature mention about aggressive features of this neoplasm. The purpose of our study was to review our experience in not only the diagnosis and management of the patients with renal PNET but also to highlight its propensity to involve inferior vena cava (IVC) and also present a rare occurrence of Ewing's sarcoma (ES)/PNET of the renal pelvis. The clinical, operative, and histopathology records of four patients of renal PNET treated between January 2017 and December 2019 were reviewed and data analyzed concerning the available literature. Out of the four patients treated, two had level III and IV IVC thrombus, and one had dense desmoplastic adhesions with the IVC wall. One of the cases had a rare presentation of ES/PNET of the renal pelvis. All patients were managed surgically, while only one patient received adjuvant chemotherapy and following up with remission for the last 2 years and 4 months. On IHC, cluster of differentiation-99 (CD-99) was positive in all patients, and three were positive for Friend leukemia integration-1. PNET of the kidney is primarily an immunohistopathological diagnosis. This neoplasm has an increased propensity for the local invasion of surrounding structures. A multimodality approach with surgery, chemotherapy, and radiotherapy could offer better outcomes, although the prognosis of these tumors remains poor.

Rare Entity of Proximal Ureteral Diverticulum Managed by Robotic Resection and Ureteroureteral Anastomosis.

Background: Ureteral diverticulum (UD) is a rare condition. It can be congenital, acquired, or an abortive ureteral duplication. Majority can be managed conservatively. The symptomatic and complicated diverticulum entails an intervention. There have been reports of UD treated with open reconstructive surgery, nephrectomy, and laparoscopic surgeries. Case Presentation: We present here a case of UD that presented with loin pain and decreased renal function and underwent robot-assisted laparoscopic diverticulectomy and ureteroureteral anastomosis. Conclusion: UD is a rare condition with only 47 cases reported in the literature. Management depends on symptoms and complications. Our case is the first in the literature to be managed robotically.

Association of spontaneous expulsion with C-reactive protein and other clinico-demographic factors in patients with lower ureteric stone.

The purpose of our study is to analyze the definitive relation of C-reactive protein (CRP) and other factors with the spontaneous stone passage in patients with distal ureteric calculus of 5-10 mm and to calculate the risk of failure of expectant management in patients. 185 patients of ureteric colic, who were subjected to medical expulsive therapy (MET), were included prospectively from August 2016 to May 2018 and followed up for 4 weeks. Patients were divided into two groups. Group A included successful spontaneous passage patients and group B included failure in the same. The parameters analyzed were age, gender, longitudinal and transverse diameter of stone, CRP, total leucocyte count, ureteric diameter and hydroureteronephrosis (HUN). We performed univariate and multivariate analysis. Receiver operating characteristics curve was used to determine the cutoff value for significantly associated variables. 122 (65.90%) and 63 (34.10%) patients were included in group A and B, respectively. In univariate analysis, CRP, longitudinal and transverse diameter of stone, HUN, proximal and distal ureteric diameters were statistically significant. However, in multivariate analysis, only negative CRP (p = 0.002), smaller longitudinal diameter of stone (p < 0.001) and absence of HUN (p = 0.005) were significantly associated with successful expulsion. Cutoff for CRP was 0.41 mg/dl and longitudinal diameter was 6.7 mm. The success rate in the group of patients with no risk factor was 96.7% and with all three risk factors was 16.7%. Patients with a longitudinal diameter of stone > 6.7 mm, HUN, and CRP > 0.41 mg/dl should be considered for early intervention. The success rate of MET can be increased to 86% after exclusion of patients with all three risk factors.

Over expression of PI3K-AkT reduces apoptosis and increases prostate size in benign prostatic hyperplasia.

INTRODUCTION: Even though the role of the phosphatidylinositol 3-kinase (PI3K)/AKT pathways and apoptosis has been well established in prostate cancer, there are no studies regarding alteration in the gene expression of PI3K/AKT pathway and protein expression of apoptotic components and their association with prostate size in Benign prostatic hyperplasia (BPH). Hence the study was designed to analyze the expression pattern of PI3K/AKT and apoptotic components in patients with BPH. MATERIALS AND METHODS: A total of 27 BPH patients aged between 55 and 75 years were recruited in the study and prostatic tissues were obtained after transurethral resection of the prostate. Gene expression levels of PI3K and AKT were assessed by q-PCR. Apoptotic components like BcL-2, caspase-3, caspase-9, BAD, and p-BAD were analyzed by western blotting and immunohistochemistry. RESULTS: Gene expression of PI3K (p85-A) (p = .02), AKT1 (p < .01) and AKT2 (p < .01), and protein expression of BcL-2 (p < .01) and caspase-9 (p < .01) were significantly increased in BPH patients with larger prostate size compared to smaller prostate size. CONCLUSIONS: Overexpression of PI3K/AKT pathway and BcL-2 were associated with reduced apoptosis and increased prostate size in BPH.

Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes?

OBJECTIVE: The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients. MATERIALS AND METHODS: The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed. RESULTS: The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%. CONCLUSION: Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.

Renal vein and vena caval thrombus: a rare presentation of emphysematous pyelonephritis.

Emphysematous pyelonephritis (EPN) can present with symptoms due to infection or sepsis. EPN presenting with renal vein and inferior vena cava (IVC) thrombus is very rare. We report a case of EPN with renal vein and IVC thrombus and its management.